Employee Wage Distribution Form

Employee Wage Distribution Form

Employer Name:    Employer Address:

Employee Name:    Employee ID/No.:

Date of Request: Month: Day: Year:

Distribution Instructions

Payroll Frequency:    First Pay Date for Distribution: Month: Day: Year:

By completing this form, the employee authorizes the Employer to direct deposit wages, net pay, and authorized deductions in accordance with the distribution instructions below. Employee understands that this authorization remains in effect until revoked in writing and processed by Employer in accordance with Employer's payroll procedures.

Bank Account Distribution (Primary and Secondary Accounts)

Account 1 (Primary) — All required fields must be completed

Account Type: Checking Savings

Deposit:    Remainder to Primary Account: Yes

Account 2 (Optional — Secondary)

Account Type: Checking Savings

Deductions and Garnishments

The following preauthorized deductions will be taken as applicable and distributed in accordance with the amounts designated by the employee or required by law. Employee shall notify Employer of any court-ordered garnishment or change in deduction instructions immediately.

Authorization and Certification

I certify that the bank account information provided on this form is correct and that I am an authorized signer on the account(s) listed. I authorize my Employer to initiate direct deposits and, if necessary, debit entries and adjustments for any amounts deposited in error. This authorization will remain in effect until revoked by me in writing and until Employer has had a reasonable opportunity to act on that revocation.

I understand that if funds are deposited to the incorrect account due to erroneous information provided by me, I am responsible for any resulting fees or charges and will assist Employer and the receiving financial institution in correcting the error. Employer is not liable for loss, delay, or damages resulting from the transmission or handling of payroll payments by financial institutions.

I further acknowledge that Employer may require a voided check or certified bank deposit documentation to verify account information prior to initiating deposits. Employer may terminate or suspend direct deposit where account verification is not provided or where the bank rejects transactions.

Change or Revocation

To change or revoke this authorization, the employee must submit a new signed distribution form to Employer's payroll or human resources department. Changes will be applied in accordance with Employer’s payroll processing schedule and may not affect the next payroll if submitted after payroll cutoff. Employer reserves the right to process changes only after account verification.

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